Data suggest that heart failure (HF) is the second most common reason for hospital admission in the US among older adults, with other evidence that those with HF who receive cardiology care during a hospital admission experience better outcomes than those who do not. With several studies documenting racial inequities in HF care and outcomes, but data lacking on whether differences exist in admission to a cardiology or general medicine service by race, Lauren Eberly, MD, MPH, and colleagues conducted a study to examine the relationship between race and admission service.
A Retrospective
“We conducted a retrospective cohort study using the electronic medical record system at our large, urban, academic referral center,” explains Dr. Eberly. “We identified all patients self-referred to the ED and admitted with a principal diagnosis of HF to either the general medicine or cardiology service. From the EMR system, we extracted self-reported race, additional important covariates, whether the patient was seen in follow-up at a cardiology clinic at our institution within 30 days of discharge, and 30-day readmission and mortality rates.”
Structural Inequities
“We found structural inequities at our institution in which patients with HF were admitted to a specialized cardiology service based on race, gender, and age,” says Dr. Eberly. “Black and Latinx patients had 16% and 19% lower unadjusted rates of admission to cardiology service of inpatient HF care, respectively. After adjustment for a variety of important demographic and clinical factors, these lower rates persisted, with black and Latinx patients having 9% and 17% lower adjusted rates (Table).” Female sex and being older than 75 were also independently associated with lower rates of admission to cardiology service.
Being seen by a cardiologist as an outpatient was also found to be a powerful predictor of where a patient would go once admitted. “This is another example of a structural driver leading to disparate outcomes,” says Dr. Eberly. “Black and Latinx patients were less likely to have an outpatient cardiologist, which was the strongest predictor of being admitted to a cardiology service. It is often easier to get a patient admitted to a cardiology service with limited beds if they are a patient of a known institutional cardiologist or if their cardiologist can advocate for them for appropriate admission. Many black and Latinx patients get into a cycle of readmission to medicine and never are able to ‘cross over’ to cardiology care, and their health likely suffers. Accessing cardiology care in the outpatient setting is thus one example of both an upstream and downstream driver of inequitable outcomes, and is one of many potential targets to improve equity. We feel that our results demonstrate that structural racism and differential access to specialty care is a driver of these disparate outcomes.”
From Documenting to Implementing
Dr. Eberly emphasize that clinicians are on the front lines, with a unique vantage point to identify and characterize inequities in care. “We want to emphasize that our results are in no way unique to HF or our institution,” she adds. “Clinicians must ask themselves daily how structural racism operates in their field and at their institution. We have the power to make important change. We also urge healthcare policy makers to remember that our current healthcare systems promote the interests of dominant group members, and recommend that care delivery be designed to prioritize the care of our most marginalized patients. We hope patients will see these results and demand transparency and accountability around issues of equity from the systems that serve them.”
The study findings are an example of the pervasiveness and detriment of structural racism, according to Dr. Eberly. “With this work, we encourage other researchers, clinicians, and administrators to see the societal and structural forces (like racism) that define race and make it relevant, but also understand how such forces can lead to differential access to care and disparate outcomes. We need to move from documenting disparities to focusing on implementation work to address them.”
Rebecca Shover